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Full text of "Managed care market area self-assessment tool for federally qualified health centers"

Oclobcr 1994 • Bureau of Primary Health Care, Health Resource Service Administration, U.S. 



..The People We Are 

PROPERTY OF 
JAN 3 1 1997 
HCFA LIBRARY 



Market Area 

Self-Assessment Tool 

for Federally Qualified Health Centers 



Health Service, U.S. Department of Health and Human Services 



Tlte People We Serve. ..The People We Are 



Managed Care Market Area 

Self-Assessment Tool 

for Federally Qualified Health Centers 

October 1994 • Bureau of Primary Health Care, Health Resource Service Administration, U.S. Public Health Service, U.S. Department of Health and Human Services 




% Department or Mmi mi & Human Services 
bureau or Pjumahv Health < ami 



Heollh Resources and 
Services Administrolion 
Bethesdo MD 20814 



Public Heollh Service 



Deal Colleague: 

1 .1111 pleased to share with yon this monograph. Managed Care Market Area 
SelJ Assessment Tool, d< signed m assist bureau funded projects in conducting an 

environmental analysis ol their market area in order to more- fully participate- 
in managed care. 

The Information presented is intended to serve as an internal self-assessment 

tool thai will allow you to lu-lier position your organization for the on-going 
changes currently taking place in the medical marketplace. 

Please he assured that this is one of many efforts underway by the Bureau to 
provide you with additional managed care technical assistance, training and 
resource documents to assure a smooth and viable transition to a more 
competitive market. 

I he dot ument reflects the combined efforts of numerous individuals both 
widiin and outside the Bureau of Primary I tealth ( !are, A special thanks to 
the Bureaus Managed Clare Task Force and the work of the primary author, 
Susan Pricdrich ol John Snow, Incorporated for bringing ibis document ro 
its final state. 

.Sincerely, 



Marilyn 1 1. Gaston, M.D, 
Assistant Surgeon t ■< u< ral 
Director 



ii 



Managed Care Market Area 8 




Acknowledgments 



In addition to members of the Bureau of Primary 
Health Care's Managed Care Task Force, special 
thanks to those outside the Bureau who provided 
comments during the development of the document: 

Sandra Knorr Pardus, Lamprey Health Care, 
Newmarket, New Hampshire 
Raymond Turner, MD, HealthPlus, Greenbelt, MD 
Ian Timm, Oregon Primary Care Association, 
Portland, Oregon 

Bureau of Primary Health Care 
Managed Care Task Force 

Central Office Staff 

Rhoda Abrams, Hubert Avent, Jack Egan (Project 
Officer], Jim Gray, Lynda Honberg, Tamara 
Johnson, Jeanellen Kallevang, Beth Tutunjian 
Regional Office Staff 

Scott Otterbien, Region 1 ; Forrest Pebbles, Region 
10; Gordon Soares, Region 9; David Weir, Region 
8; Rick Wilk, Region 5 



Acknowledgments 



iii 



Table of Contents 

Acknowledgments iij 

Introduction v 

I. Characteristics of Community Served 1 

II. Consumer Preferences 7 

III. Trends in Health Care Delivery 15 

IV. Traditional Partners 23 

VI. Market Position of Managed Care Plans/Networks 31 

Appendix 1 : Patient Satisfaction Survey 45 

Appendix 2: List of State, Regional and National Organizations 50 

Appendix 3: Managed Care Organization Performance Indicators 70 



iv Managed Care Market Area Self — Assessment tool 



Iffitalwtiffl! 



The United States is in the midst of an extensive 
and rapid transformation of its health care system 
which is significantly affecting the programs of the 
Bureau of Primary Health Care (BPHC). Two 
interrelated trends are of immediate and critical 
importance to Bureau programs: 

1 . The inexorable, and in many places very 
aggressive movement to managed care; and 

2. The organization of previously independent 
health care providers into integrated networks. 

These trends are intertwined as health care 
organizations recognize that working 
collaboratively with other providers has the 
potential to strengthen their competitive position, 
reduce risk and assure the requisite continuum of 
care in a managed care system. 

How ready are you to change? Your long-term 



Introduction 



financial viability will likely depend on your ability 
to manage your patients effectively and your 
success in affiliating with the right partners for the 
purposes of providing managed care. BPHC funded 
programs should be thinking seriously about or 
already investigating opportunities for developing 
managed care networks and/or partnerships with 
other organizations. Some of these organizations 
may be traditional partners; some may not. 

In making decisions about participating in 
managed care networks, health centers must 
balance the need to participate in the health care 
system while retaining the community orientation 
and control that has been a central strength of 
Bureau programs since their inception. This tool is 
designed to assist you in assessing the specific 
health care marketplace in which you operate and 
opportunities for retaining and enhancing market 
share. This understanding extends beyond your 
patients and community to include an 
understanding of how and when managed care is 
developing both in the public (e.g., Medicaid/ 
Medicare] and private sectors; who the significant 
providers are and which of these are competitors 



and/or potential partners; how the health center is 
perceived by insurers, providers, employers and 
consumers; and how community demographics and 

hei illli ni'i'd', <-v. Jviiic| 

This tool provides a "snap-shot" of your threats and 
opportunities at a particular point in time. Through 
the exercise of completing this tool you will identify 
potential partners and areas of further assessment 
which may help you to position your organization 
in these changing times. Since the results of the tool 
are predicated on your current circumstances, you 
should consider repeating the exercise on a regular 
basis as your local circumstances change and as 
State and national reform efforts continue to take 
shape. 

This assessment tool is designed to complement the 
Bureau's Managed Care Internal Operations 
Self-Assessment Tool. The results of the internal 
assessment document the organization's operational 
readiness to contract for managed care and its 
capacity to handle risk in a managed care setting. 
The market area assessment identifies trends in your 
marketplace and key players in the managed care 



vi 



Managed Care Ma 



arena and provides a means to evaluate options for 
participating in managed care networks. Together, 
the two tools identify strategies which reflect the 
dynamic interplay between internal strengths and 
weaknesses and external opportunities and threats. 

The Managed Care Market Area Self- 
Assessment Tool is divided into six sections: 

1 . Characteristics of Community Served 

2. Consumer Preferences 

3. Trends in Health Care Delivery 

4. Traditional Partners 

5. Market Position of Managed Care 
Plans/Networks 

6. Alternatives for Integration 

Each section includes an introductory paragraph, 
suggested sources of information, a series of 
questions and an action plan. 



k e t Area Self — Assessment Tool 



■s 1 



Assess the 
organization's current 
market position in 
terms of who in the 
community is being 
served. It is always 
easier to keep your 
existing clients than 
to find new ones. For 
this reason, it is 
critical to identify key 
user groups and to 
assure you can 
continue to serve 
them as your local 
health care 
system changes. 



HARACTEIWTICS OF COMMUNITY SERVED 



How well do you know your users? Can you identify major user groups 
(e.g., sociodemographic, ethnic, racial and cultural groups)? 

II 3 4 5 

DON'I KNOW IHEM KHOW IHEM WELL 

\^Aiat trends are you seeing for these key user groups? 

II 1*5 
DECREASING GROWING RAPIDLY 



Information Source: Service area maps with zip codes or census tracts can be obtained 
from the local (City or Countyl Planning Commission. Define the service area using the 
BPHC's Needs/Demand Assessment methodology. Sociodemographic data on your service 
area(s) can be obtained from Census data and local planning agencies. A list of major 
employers can be obtained from your local Chamber of Commerce. Informalion on insurance 
coverage provided by employers can be obtained by calling the organization's personnel 
department. Information on Medicare, Medicaid, and commercial insurers can be purchased 
from CACI. 



2 Managed Care Market 



Characteristics of 
Community Served 



Obtain a map of your city or area. Draw a line 
around the area you currently serve (where 
your patients come from). Draw a second line 
around the area that you feel you could 
potentially serve. 

Complete Table 1. Define the socio- 
demographic characteristics of your user 
population. Enter total health center users for 
the past two years and current year in columns 
1-3, respectively. Compare with the socio- 
demographic characteristics of residents in your 
current (column 4) and potential service area 
(column 5). Calculate the health center's current 
marketshare by dividing health center users 
(column 3) by the current community population 
(column 4] and enter in the last column. 



a Sell-Assessment loot 



Table 1. Sociodemographi 

Health Center Users 



c Characteristics 

Community Population Marketshare 



Characteristic 


1 2 


3 


4 5 


(3/4) 


19 19 


19 


Current Potential 


Total number of people 








-« 




% youngest (0 - J) 










O 
S 


% middle oges ( - ) 
% oldest (LJ-L3) 














s 














POVERTY 


% < 100% of poverty 

X 100 - 200 

% > 200% of poverty 








































% mole 
% female 














" 














MINORITY 


% Slock 
% Hisponic 


























% other: L. 1^ : _ 1 














(3 


% Medicaid 
% Medicare 
% private insurance 
% uninsured 
% managed core 


























o 














1 





























3 



This is the health 
center's marketshare. 
Circle all numbers in 
the last column of 
Table 1 which are 
greater than this 
number. These groups 
represent the health 
center's market niche. 



Characterist 



i c s o 



t Community Served 



3 



4 Perform a portfolio analysis using the data 
"•|" •"<••! in Table 1 and youi own knowledge 
of the area. Evaluate the health center's market 
penetration for selected user groups (i.e., 
minority populations, income levels, insurance 
coverage, etc.) and the likely growth potential 
for these groups based on the health center's 
and the community's historical trends. 




For example, □ user group |such as 
MedrcaidI which represents a high 
percenlage of users compared to Ihe 
populolion and hos been increasing 
over time would appear here. 



^m^^ HIGH 

Health Center's Market Penetration 

Managed Care Market Urea Self — Assessment Tool 



S Identify major employers of health center users 
and list the insurance programs they offer. 
Circle any insurance programs which the health 
center does not accept. 



Table 3. Health Center Users' Employers & Insurance Coverage 

Employer Health Insurance Plans 



Characteristics o ( Community Served 



Analysis o! findings 

We serve users and have % 

markelshare in our primary service area. Key user 
groups include 



These patients represent our market niche. Loss of 

our population 

will have the greatest negative impact on our 
practice because they represent our largest user 

group(s). The uninsured represent % of health 

center users as compared with % of the 

service area population. Recent trends show 



significant growth in 

population groups, while our practice has show a 
increase/decrease in these population groups. 
We are/are not affiliated with major insurance 
programs offered to the employed persons in our 
health center. 



I 



Managed Care Market Area Self — Assessment lool 



ONSUMER PREFERENCES 



Assess users 
satisfaction with the 
health center's 
service delivery 
system. A critical 
short-term strategy 
is to assure users 
are satisfied so they 
will choose to 
remain users of your 
service in the event 
that some financial 
barriers to care 
are removed. 



How well do you know your users' needs and preferences? 

3 



I 1 
DON'T KNOW THEM ••• 



k 5 
KNOW IHEM WELL 



How likely are selected user groups (e.g. major sociodemographic, ethnic, 
racial and cultural groups] to choose to use your services if they have an 
option? 



I 2 
LIKELY TO LEAVE 



4 5 
IURE TO HAY 



Information Source: If information is not available to answer these questions, the health 
center is encouraged to conduct a survey of current users. A sample survey instrument and 
instructions ore included as Appendix T . 



Consumer 
Preferences 

IHow satisfied are selected user groups (e.g., 
sociodemographic, ethnic, racial and cultural 
groups) with the health center? Refer to the 
survey instructions in Appendix 1 to calculate 
a numeric rating. Alternatively, use a qualitative 
scale such as very good, good, fair, poor. 



Managed Care Market Area Self — Assessment Tool 



Table 4. Assessment of User Satisfaction 



User Group 



Satisfaction Rating 



Quality 



Scope of seivice 



facilities 



Hawredcd staff 



Medical staff 



ftirayCoroftwida 



Owmll 



% Who Would 
Recommend 
to Friend 



Medicaid 



Medicare 



uninsured- employed 



uninsured- unemployed 



private insurance 



Consumer Preferences 



2 In addition lo financial barriers, what barriers 
to care do selected user groups identify which 
inhibit their ability to obtain health care 
services (i.e., transportation, cultural, language, 
etc.)? To what extent has the health center 
addressed these barriers? 



Table 5. Barriers to Acce 



User Group Barrier to Access 


Health Center Response 


Adequate 


Needs Improvement 



































































Managed Care Market Area Self — Assessment Tool 



i 



What hospilal(s) is preferred by selected user 
groups for obstetrics, pediatrics and general 
medical? 

Table 6. Preferred Hospital Affiliation 

Preferred Hospital 

User Group 



Obstetrics 



Pediatrics 



Medicaid 



Medicare 



uninsured — employed 



uninsured — unemployed 



private insurance 



Consumer Preferences 



How likely are selected user groups to use (he 
health center if they have financial access to 
other primary care providers? 



User Group 



ble 7. Assessment of User Retention 

Likelihood of Retaining User 



Very likely 



Somewhat likely 



MmIkiiiiI 



Motlfcoio 



Untaioil-omiiloyod 



Untaod-unoiniiloyoi) 



Privnto msuionca 



12 



Managed Care Market Area Self — Assessment Tool 



Analysis of findings 

Overall, our users are 

satisfied with our health service delivery model. We 
are at greatest risk of losing our 

users 

with the removal of financial barriers to access. 
Reasons for seeking care elsewhere include 



Additional barriers to care were identified by users 
and include 



We are effectively meeting the needs of 



but not 



We are affiliated with the hospital(s) preferred by 



We are not affiliated with the hospital(s) preferred 

by . 



Consumer Preferences 



14 



Managed Care Market Area Self — Assessment lool 



Be familiar 
with the direction 
health care reform 
and managed care 
are taking in your 
local area and 
your State. 



RENDS IN HEALTH CARE DELIVERY 

Who, is the attitude of State policy makers towards federally qualified health centers 
(FQHCs) such as yours? 

12 3 4 5 

DON'T SUPPORT tIRONGlY SUPPORT 

Whoti s the attitude of the State Medicaid program toward FQHCs such as yours? 

II 1*5 
DON T SUPPORT STRONGLY SUPPORT 

Who, is the attitude of private managed care programs (e.g., HMOs, HIOs, MCOs, etc.) 
towards FQHCs such as yours? 

II 3 4 1 
HOT INTERESTED VERY INTERESTED 

\^Aiat is the attitude of private health care providers (i.e., hospital specialists and 
ambulatory care providers) towards FQHCs such as yours? 

II 3 * I 
NOT INTERESTED VERY INIERESIED 

Information Source: If you are unable to answer these question, you should contact your slate, regional and 
national associations. A list of contacts is included in Appendix 2 for State Primary Care Associations, 
Regional Primary Care Associations, Cooperative Agreements and national organizations. Additional sources for 
this information include the Governor's Office in your stale, the Medicaid Office and the Deparlmenl of Health. 



15 



Treads in Health 
Care Delivery 

IWhat is the status of health reform in your State 
(i.e., legislation passed, date of implementation, 
etc.)? 



IE 



Managed Care Market Area Self — Assessment Tool 



2 Who are the key players in designing health 
care reform in your State? List the names of 
individuals [e.g., legislators, consultants, etc.) 
and/or organizations (e.g., medical society, 
hospital association, insurance companies, 
businesses, consumer groups, etc.] active in the 
health reform debate. 



Trends in Health Care e I i i 



What is the health center's involvement in 
health reform activities? How are the interests 
of federally funded programs like yours being 
represented? 



What is the State's approach to meeting the 
health care needs of the general population? 



Table 8. 


Overview of State Aaaroach 


Issue 


Current Situation 


Health Reform Proposal 


Gonoml approacli 


njblic/pnvale mixture ndmimsterad by insurance companies, 
Slolos, Federal governmenl anil large and small businesses. 




(OVOIIigO 


Voluntary coverage 




Donoflts 


No slondoid benefits potkoge 




Premiums, msl sinning unci oul ol |][i(kol pnyrnrinls Voluntas employer contributions to insurance premiums, 
no (osl slurring and oul ol pocket limits 




Flnanclnn 


General lax revenues foi public programs 




(osl (onliiinmonl 


UR and mnaaged core oiiannements in private seder. 
Prospective paymoal system, UR and RBRVS based tee schedule 
under Medicare. Lowei provider reimbursement ond movement to 
monnged cure in Medicnid. 




Piovldn ralmbuisoitionl 


FFS paid ol some percentage of usual and customary rote 
charged by providers ia an orea; Medicare RBRVS fee schedule 
established by Federal government; Medicoid lee schedule established 
by Stales; Capitated plans negotiate rotes with iadividuol ptovideis. 




Reforms in lioollli Insurance 


No guarantee that covoroge must be offered to oil individuals or 
portability between jobs. Pre-existing clauses con exclude coverage lor 
certain illnesses/conditions (some States regulate these practices), 
torge ond small companies ore rated bosed on their claims experience. 





11 



Managed Care Market Urea Self — Assessment Tool 



1 
i 



Is the State seeking a waiver of Medicaid 
requirements, such as in a Section 1115 
waiver? Yes or No 

If yes, is the State expanding eligibility for 
Medicaid benefits? Yes or No 

If yes, what additional categories of individuals 
will be eligible for Medicaid? 



□ Children up to the age of 

□ Single adults up to 

level 



% poverty 



Is the State seeking a waiver of FQHC 
requirements? Yes or No 

If yes, what is the waiver for and what is the 
status of the application? 



Is the State pursuing a managed care strategy 
for its Medicaid program? Yes or No 

If yes, analyze the managed care arrangements 
for Medicaid eligibles. Complete Table 9. 



Trends in Health Care Delivery 



Table 9. Medicaid Managed Care Program 



Program Element Selected Options State's Medicaid Managed Care Program 



ly|io of omohionl 


Mandatory 01 voluntoiy 




Coloootlos ol ollgiblos iocludod 


AFDC lomilios, SSI individuals 
{ayed, blind and disabled), oldcrly 
aad disabled Medkoio beneficiaries, 
goootal assistance population, 
cliildten, piegnont woman, olhei indigonl 
persons, elc. 




Eliglblo contractors 


Full risk HMOs, primary core 
organizations, olc. 




Payment molhoils 


FFS, FFS wilti case rnanogei fee, 
FFS wilti shored savings opportunities, 
copitotion, olc. 





Managed Care Market Area Self — Assessment Tool 



9 Are specific categories of Medicaid eligibles 
excluded from the managed care program? 

□ Homeless 

□ Migrant farmworkers 

□ Persons with HIV/AIDS 

□ Undocumented 

□ . 

□ . 

i 
I 



Trends in Health Care Deli 



What is the State's approach to protecting the 
array of services and the infrastructure of 
providers that care for low income people? 

□ Risk adjusted payment rates 

□ Access to financial markets for infrastructure 
development 

□ Subsidies for public providers 

□ Requires health plans to contract with 
essential community providers 

□ Grants for enabling service 

LI Capital for infrastructure development 

□ Guaranteed cost based (FQHC) 

□ . 

□ . 



21 



Analysis of findings 



Health reform activities in our State, 
are likely to be implemented by 



FQHCs have played a role in 

development of the Slate's approach to health 

reform. The health center has been 

involved and remains informed 

as health reform efforts evolve. 

Overall, the State's approach to health reform for 
the general population involves a strategy of 



In addition, the State modification of the Medicaid 
program will affect FQHCs by 



As a result, the health center can anticipate 
support from the State in terms 

of 



Managed Care Market Am Self — Assessment Tool 



®s S, 





Assess 




opportunities for 




establishing formal 




network 




arrangements with 




traditional partners. 


1 


Just as it is easier to 


3k 


retain existing 




patients, it is easier 




to formalize 




rplntinnc with 

ICIUIIUII9 Willi 




organizations which 




have traditionally 


=a 


viewed you as a 




partner. 


=3 




=3 




r3 




■1 




=3 




dl 













RADITIONAL PARTNERS 

How aggressively are your traditional partners pursuing managed care? 

11 3 4 5 
NOT rUIUUING PURHIING AGGREItlVELY 

How competent are your traditional partners in managed care services 
delivery? 

12 3 4 5 
HOICOMPEKHI VERY COMPEIEHI 

How would you rate your traditional partners in a managed care 
environment? 

II 3 4 5 
WEAK 

Information Source: Traditional partners include those organizations with whom the 
health center has formal (i.e., written) and informal (i.e., working but not supported in 
writing] arrangements as well as organizations with a similar mission and commitment to 
the health center's target populations. 



23 



24 Managed Care Market 



Traditional Partners 



Complete Table 1 0. List key provider 
organizations (e.g., insurance plans, FQHCs, 
other primary care providers, specialists, and 
hospitals) who may be likely partners with the 
health center. 



a Self — Assessment Tool 



1 o. 

Organization 



Traditional Partners 



Type of Provider (e.g., refer to list in Table 1 1) 



Traditional Partners 



2 Are traditional partners other primary care 
organizations (horizontally integrated) or do 
partners include specialists and tertiary care 
facilities (vertically integrated)? 



Among the health center's traditional partners, 
could a vertically integrated network be 
established with primary care, specialty care 
and hospitalization? Table 1 1 lists possible 
services to be covered. Indicate with an "x" if 
the health center provides the service. For those 
services which the health center does not 
provide, identify a potential partner(s). 



Managed Care Market Urea Self — Assessment Tool 



Table 11. Covered ServiceflHI^HHMHHB 
Covered Services CHC Provides Potential Partner(s) 





Pediatrics 






< 


Internal Medicine 








Family Practice 








OB/GYN 








Cardiology 








Orthopedics 






5 


Dermatology 






fc: 


Ophthalmology. 


- 






Allergy 








Pulmonary 








Other 








Pediatrics 








r\D /run 
Ud/utN 






z 


Med/Surg 






z 


Mental Health 








In & Out Surgery 






o 


Intermediate Care 








Tertiary Services 








Emergency 







Traditional Partners 



Table 11. Covered Services ronf. 

Covered Services CHC Provides Potential Partner(s) 





lolioioloiy 








DIOQnostll Kodiology 








MniiiniO{|[ii|)l)y 








Pltoimocy 






I 


0|)lkiil [yo Coio 






I 


ShoFlloini Homo lloollh 






1 


Ilmrapy (Ok, Pliys, old 








Oulpl Montal lloulih 








Subslanco/ Alcohol Atiuso 








Podioliy 








tabid Midi Equipnioitt 







Managed Care Market Area Self — Assessment Tool 



On a scale of 1 to 1 0, how would you rate 
your traditional partners on the following? 



F 

I 

I 



3 

I 

I 

I 

I 

I 

» Traditional Partners 
i 



Clinical and administrative management skills to 
support managed care? 

123456789 10 

Infrastructure to support managed care? 
123456789 10 

Commitment to vulnerable populations? 
123456789 10 

Relative experience and position in the managed 
care marketplace? 

1 23456789 10 

Capitalization potential of parties? 
123456789 10 

Willingness to integrate services? 
123456789 10 



Analysis of findings 

Considering the health center's existing 
relationships, the health center could develop 
a vertically/ horizontally integrated 
network. Overall, the health center is 
affiliated with weak/adequate/strong 
managed care partners. 



Managed Care H a r I e 



t Urea Self — Assessment leol 



53 



ARKET POSITION OF MANAGED CARE PLANS/NETWORKS 



Assess opportunities 
for establishing formal 
network arrangements 
with non-traditional 
partners. Although it is 
easier to formalize 
relations with traditional 
partners, in some 
circumstances non- 
traditional partners may 
be preferred. Non- 
traditional partners may 
be preferred by health 
center patients, may 
have a better reputation 
in the community and 
may be better positioned 
to succeed in the 
marketplace. 



Xo what extent have managed care networks been established in your 
market area? 

12 3 4 5 

HOI EtIABLIIHED Will EtTABUIHED 

How would you rate your managed care "team" relative to the competition? 



WEAK. 



• yiiuni; 



How interested are major managed care planjs] to include you in their 
networks? 

12 3 4 5 
NOT INTERE1IED VERY INIEREIIED 

Information Source: Information on managed care plans operaling in your aroa can bo 
obtained from the Division of Insurance, yellow pages, employers, American Medical Care and 
Review Association, State Primary Core Association, stale and local medical associalions, stale 
offices of health planning, stale insurance commissioners, Chamber of Commerce and "help 
wanted" ads. Information on individual managed care plans can be obtained from the managed 
care plan's Provider Relations Department (request credenlialing procedures), DHHS' Office ol 
Prepaid Health Care, State regulatory agencies (Stale Division of Insurance) and word of mouth. 
To complete the financial portion of Table 12, refer to the annual slatemenl prepared for the 
Slale Deparlment of Insurance. Definilions for calculating the indicators are included in Appendix 
3 and refer to specific reports/schedules of the NAIC Annual Slatemenl, HMO-Associalion Edition, 
revised 1990. Information on hospitals is available from the American Hospital Association and 
your local health deparlment. 



31 



32 Managed Care 



Market Position of 
Managed Care 
Plans/Networks 



1 Complete Table 12. List all managed care 
plans operating in your service area (including 
plans the health center already contracts with] 
and compare them on the following criteria. 



r e a Self — Assessment loot 



Table 12. Comparison off Managed Care Plans 

Description of Plan Managed Care Plans 



Nome of Plan 










Z 

o 


Model (e.g. staff, IPA) 










i 

o 


Yrs in operation 










4ERAL IN 


Market oieo 










S 


Federally qualified 












Current 










EMBERSH 


Morketshare 










X 


Projected growth 










=> 
o 


% Medicaid 










z 

X 


% Medicore 












% Employed 










d 

z 


Major employer groups 












Average family premium 










FINAN 
PROF 


Aveioge primary core capitation 
per member, per month 










z 
o 


Providers 










p 


Consumers 










Ifla 


F 1 B t P S i 


ion of 


III a o a g e 


1 Care 


P 1 a o s / H o 



Si 



From Table 12, identify the managed 
care plan(s) with: 

U the greatest marketshare: 

□ commitment to vulnerable populations: 

□ established market position: 

□ the greatest projected growth: 

□ the greatest % Medicaid enrollment: 
L) the best reputation with patients: 

U the best reputation with providers: 

□ the best financial position 



Is the health center affiliated with these 
managed care programs? If not, why? 



works 



33 



1 Table 12. Comparison of Managed Care Plans cont. 

Financial Position of Plan Managed Care Plans 



Name ol Plan 










j 


lolol iovoiilio 
Not income 
Not Willi 

0|Moling niolil moigin 


































— 3 
a 5 


Dnys cosh on hand 

Rnlio of (ash lo claims poyoblo 


















|j 


Days In tocoivublos 
Doys in unpaid claims 




















Ailmilloil iosoivos 

Slolo minimum iosoivo loquiioinonls 



















4 Complete Table 13. List major hospitals 
(public and private] operating in your service 
area (including hospitals the health center 
already contracts with) and compare them on 
the following criteria: 



Managed Care Market Area Self — Assessment loot 



Table 13. Comparison off Hospitals 



Description of Hospital 



Hospitals 



Name of hospital 












Commitment to vulnerable populations 










O 
£ 


Control 










O 
z 


Yeois in operation 










z 


Service oreo 
JCAHO Accreditation 










o 










INPATIENT DATA 


Beds (by service) 
Average occupancy rate 
Average length ol slay 




























Per diem/expense per inpatient day 
Expense per admission 










o 










AFFILIATIONS ' 1 


Managed Core Organizations 

Universities 

Primary care providers 


























«x 


Obstetrics 

Pediatrics 

Medical/surgical 

Mental health/Substance abuse 

Tertiary 


















z 










z 
o 










< 










SSI 
gai 














Providers 
Consumers 





















From Table 13, identify the hospital(s) 
with: 

LI commitment to vulnerable populations: 



□ affiliations with managed care plans 
identified in Question 2: 



lj the best reputation with consumers: 



U the best reputation with providers: 



□ reasonable costs: 



Bis the health center affiliated with these 
hospitals? If not, why? 



* list organizations 



Market Position of Managed Care Plans/Hetworks 



35 



7 Complete Table 14. For those specialty 
services for which the health center currently 
does not have access and needs, identify 
major specialty providers operating in the 
service area who are affiliated with key 
hospitals identified in Question 5 above and 
who are likely partners. 



36 



Managed Care Market Area Self — Assessment lool 



4. Selected Primary Care and Specialty Providers I 

Commitment to Reputation 



Patients populations 
Provider Service Area (yes or no) Capacity (yes or no) 


Provider 


Consumer 

































































































































Market Position o ( Managed Care Plans/Networks 



Analysis of Findings 

The health center has no working relations with 

managed care plan(s) 

which is/are well positioned in the marketplace 
based on marketshare, commitment to vulnerable 
populations, cost and reputation. Similarly, the 
health center has no working relations with 

hospital(s) which is/are well 

positioned in the marketplace based on 
marketshare, cost and reputation. The health 

center's arrangements with 

managed care plan(s) and 

hospital(s) continue to be strategically appropriate. 



Managed G a r e M a r k i 



The health center should reconsider its affiliation(s) 

with managed care planjs] and 

hospital(s). 

The health center should consider developing 
specialty arrangements in the following areas, 
including 



Am Self — Assessment Tool 



LTERNATIVE5 FOR INTEGRATION 



Identify options 
for establishing formal 
network arrangements with 
traditional and/or non- 
traditional partners 
recognizing that successful 
partnerships complement 
internal strengths and 
weaknesses. Options will 
depend on the unique 
opportunities that exist in the 
health center's marketplace, 
including the willingness of 
various organizations to be 
partners and the need to 
retain access to key user 
groups. The health center 
should give careful 
consideration to its own 
internal managed care 
strengths and weaknesses in 
evaluating various options. 
This is particularly important 
if the health center is 
considering assuming any 
financial risk. 



How far along is the health center in formalizing its managed care 
relationships? 

12 3 4 5 
HOI (TARTED fINIIHED 

How well positioned is the health center in the managed care 
marketplace? 

12 3 4 1 
POORLY POSITIONED WEL1 POIIIIOHED 

To what extent do you need to reevaluate your traditional partnerships to 
be competitive and have access to key user groups? 

1 2 3 4 S 

GREAI EXIENl NO NEED 10 REEVALUATE 

Information Source: The health center should complete the Managed Care Internal 

Operations Self-Assessment Tool lo document the organization's operational readiness 
to contract for managed care and its capacity to handle risk in a managed care selling. This 
information should be considered in evaluating options for participating in managed care 
arrangements. If the health center requires assistance in evaluating or pursuing network 
options, technical assistance is available through your Regional Office. 



40 Managed Care M a r k e 



Alternatives for 
Integration 



i 



Which, if any, managed care organizations 
appear to be critical to the success of the 
health center in a managed care environment? 
(p. 33, Question 2) 



2 



Is the health center affiliated with these 
managed care plans? Yes or No 



Area Self — Assessment Tool 



1 



Horizontal integration 

Will participation in a horizontally integrated 
network of primary care providers provide the 
health center with a better negotiating position 
with managed care plans and assure continued 
access to key user groups? Yes or No 

4 Can the health center establish a horizontally 
integrated network with traditional partners? Do 
these partners have or could they acquire the 
_ management skills and infrastructure to establish 

and operate a successful horizontally integrated 
network (network of primary care providers)? 
, Yes or No 

5 Which traditional partners appear to be critical 
to the success of the health center in a 
managed care environment? 

B 





7 Does the health center need to consider non- 
traditional partners to be included in a 
horizontally integrated network to effectively 
position itself in the managed care 
marketplace? Yes or No 

Q Which non-traditional partners appear to be 
U critical to the success of the health center in a 
managed care environment? 



Alternatives tor Integration 

i 



11 



Vertical integration 

9 Will the health center need to be part of a 
vertically integrated network to assure 
continued access to key user groups? 
Yes or No 



Can the health center establish a vertically 
integrated network with traditional partners? Do 
these partners have or could they acquire the 
management skills and infrastructure to establish 
and operate a successful vertically integrated 
network (network of primary care providers, 
specialists and hospitals)? Yes or No 

Which traditional partners appear to be critical 
to the success of the health center in a 
managed care environment? 



1 



12 



13 



Does the health center need to consider non- 
traditional partners to be included in a 
vertically integrated network to effectively 
position itself in the managed care 
marketplace? Yes or No 

Which non-traditional partners appear to be 
critical to the success of the health center in a 
managed care environment? 



Complete Table 15. List the health center's 
five major strengths and weaknesses related to 
managed care. 



Managed Care Market Area Self — Assessment I 



Table 1 5. Self Assessment off Managed Care Strengths & Weaknesses 

Strengths Weaknesses 



Alternatives {or Integration 



13 



|r In reviewing the health center's managed care 
||| strengths and weaknesses, does the health center 
have the necessary management and systems 
capabilities to support the network arrangement 
which is most appropriate for the marketplace? 



IV 1 11 iti'iihul | mi Inci iilcnlilioi I thn nigh this 
analysis complement the health center's strengths 
and weaknesses? 



Wlf the health center has entered into or plans to 
enter into a managed care network, does the 
preceding analysis support the selection of 
partners and the configuration of the network? 



1 



44 Managed Care Market Area Self — Assessment Tool 



APPENDIX 1 

Patient satisfaction survey 



Appendix t 



15 



The purpose of the Patient Satisfaction Survey is 
lo evaluate the likelihood of patient retention based 
on satisfaction with various aspects of clinic 
operations. 

Instructions for Survey Administration 

In order lo have an unbiased sample of patients, 
the goal of the study is lo have every patient 
visiting the health center over a one week time 
period complete a survey instrument. If less than 
100 patients are seen in a week, continue until 
100 surveys have been completed. Patients who 
visit more than one time during the week should 
only complete the survey once. 

The survey is designed to be self-administered to 
literate patients. Patients who are not literate should 
be interviewed by a staff member in order to 
complete the survey, if possible. A site-specific 
protocol must be developed to insure that all 
patients complete and return the survey at the time 
of their visits. For example, a patient could receive 
the survey at check-in and be asked to return the 
survey before seeing a provider. 



Instructions tor analyzing survey results 

All surveys should be tabulated as follows: 

1 Questions 1 -5 and 7: For each question, 
tally the number of each response (e.g., 
excellent, good and fair). A score (e.g., 5,3,1) 
has been included under selected responses. 
A weighted average for each question can be 
calculated by multiplying the number of 
responses by the score. For example: 

How would you rate the quality of health 
services provided at the center? 

ewellenl good foil pool 

i 3 10 

If 1 people "x" excellent, 5 people "x" 
good and 2 people "x" fair, a weighted 
average is calculated as follows: (10x5) + (5 
x 3) + (2 x 1) = 67 points. 

By dividing the total number of points by the 
number of responses (n=17, for example), the 
weighted average equals 3.9 which 
corresponds with a rating of very good. 



Managed Care Market Area Self — Assessment Tool 



z 



Questions 6, 8-13: For each question, tally 
the number of each response and calculate the 
percentage of total responses for each 
response. For example: 



Would you recommend the center to a friend? 

yes no 

If 1 people "x" yes and 6 people "x" no, 
the percentage of total respondents for each 
response would be: 



1 



10/16 = 63% yes 6/16 = 37% no 

Questions 1-7 correspond with the 
satisfaction categories on Table 4 as follows: 

• column 1 (quality) and question 1 

• column 2 (scope of service) and question 2 

• column 3 (facilities) and question 3 

• column 4 (non-medical staff) and question 4 



Appendix 1 



column 5 (medical staff) and question 5 

column 6 (primary care provider) and 
question 7 

column 8 (% who would recommend ) and 
question 6 

Column 7 (overall) should be a weighted 
average of question 1-5 & 7. 



Q. 0. 



1 



1 1 

It 
1 1 



5 I 



o = 



f f 

II 



3 
10 



c 
o 



D 



o 



- .f f 



o 
a 



~ o i- 



o 2 





| J 

o -o 

2 s 



'I » 

S § 

£ i 

•5 s 



1 1 



^ a, 



t 
" 



V 

1 I 

S 

1 - 



48 Managed Care Market Area Self — Assessment 1 o o I 



3 



2 £ 



£ "5 

5 ? 

Q- 

£ i £ 



Appendix 1 



49 



APPENDIX 2 



List of State, Regional & National 
Organizations 



50 



Managed Care Market Area Self — Assessment fool 



NATIONAL 
ORGANIZATIONS 



American Academy of Family Physicians (AAFP) 

8880 Ward Parkway 

Kansas City, MO 641 14-2797 

Phone: 816-333-9700 or 800-274-2237 

Fax: 816-822-9715 

The Academy with more than 75,000 members, is a 
professional society which promotes and maintains standards 
for family doctors who provide comprehensive health care to 
the public. Other major purposes of AAFP include, the 
advocacy for and education of patients and the public in all 
health-related matters; preservation and promotion of quality 
cost-effective health care, and to provide advocacy, 
representation and leadership for the specialty of family 
practice- An Annual Scientific Assembly for continuing 
education is held each Fall. Publications include the journal, 
American Family Physician; a newsletter, AAFP Reporter; 
Family Practice Research Journal, and Family Practice 
Management which reports on practice management and 
socioeconomic issues. 



Appendix 2 



American Hospital Association (AHA) 

One North Franklin 
Chicago, IL 60606-3401 
Phone: 312-422-3000 
Publications: 800-AHA-2626 

The AHA membership consists of more than 54,000 
individuals and health care institutions including hospitals, 
health care systems and health care delivery organizations. 
The Association advocates in various areas including 
Congress, the courts, public policy forums and grass roots 
activities. The AHA carries out research and education 
projects and has an annual conference. The AHA Rosourco 
Center has more than 57,000 volumes, 1,000 periodicals and 
a database on health care planning and administration. AHA 
serials include the AHANews, Hospitals, and Hospitals & 
Health Networks. The 100 plus page publications catalog 
includes such titles as, Transforming Health Care Delivery: 
Toward Community Care Networks; Physicians in the 
Management of Risk in Managed Care Contracts; AHA Guide 
to the Health Care Field, and Trustees and the Integration of 
Community Health Care. 



Association of State and Territorial Health Officials 

415 2nd St. NE, Suilo 200 
Washington, DC 20002 
Phono: 202-546-5400 

ASTHO represents stale and territorial heallh officers on 
mallors of fodoral heallh, logislalion and policies. The 
association also aids public or private agencies dealing with 

h'"ilth illy i" inlcrslrjli! ami federal lelalionships 

ASTHO holds quarterly AIDS meetings. Publications include a 
periodic newsletter, the biennial Stale Public Heallh Agencies 
and a directory of state heallh departments. 

American Managed Care and Review Association 
(AMCRA) 

1 200 1 9lh Street, NW, Suite 200 
Washington, DC 20036-2437 
Phone: 202-728-0506 
Fox: 202-728 0609 

AMCRA is tho advocate (or more than 500 managed care 
companies and the only national trade association 
representing the lull spectrum of managed care including 
HMOs, PPOs, IPAs, PHOs and HIOs. Some of the activities in 
which the AMCRA is involved include legislative tracking of 
stale and federal heallh policies, building coalitions with other 
national and stole health care associations, researching and 
assessing legislation and regulatory issues and providing 
technical assistance in medical and administrative issues. 
AMCRA's Department of Education offers seminars, 
conferences and certification programs designed for managed 
care professionals. Publications include, The Managed Heallh 
Care Directory; The Managed Heallh Care Overview; The 
Managed Care Executive Survey, and the bi-monthly 



newsletter, The Monitor. A publications price list is available 
on request. 

American Medical Association (AMA) 

5 1 5 North State Street 
Chicago, II 60610 
Phone: 3 1 2-464-5000 
Fax: 312-464-4184 
Publications: 800-621-8335 

The American Medical Association is a service organization 
of nearly 300,000 physicians. The AMA represents the 
profession in legislative and regulatory matters, maintains a 
library and participates in setting standards for medical 
schools, hospitals and medical education courses. The 
Association provides information to members and the public. 
Publications include, Managed Care Desk Reference; Making 
Managed Health Care Work; The Managed Heallh Care 
Handbook; Administrative Costs and the Debate About US 
Heallh System Reform: A Review of Lileralure; Slate Heallh 
Care Data and American Medical News a weekly 
newspaper. A catalog is available on request. 

American Public Health Association (APHA) 

1015 Fifteenth Street, NW, Suite 300 
Washington, DC 20005 
Phone: 202-789-5600 
Fax: 202-789-5661 

The Association is the largest organization of public health 
professionals in the world, with over 32,000 members from 
77 public heallh occupations. APHA actively serves the 
public, ils members, and the public health profession in four 
major areas: scientific development, advocacy, publications 



Managed Care Market Area Self — Assessment Tool 



and an annual meeting. There are more than twenty APHA 
sections and special primary interest groups which provide an 
opportunity for members to pursue specific interests. Some of 
the groups are: Health Administration, Medical Care, 
Community Health Planning ond Policy Development, and the 
Health Law Forum. Current priorities and activities of each 
group is available from APHA. Publications include, The 
Public Health Law Manual; A Guide to Medical Care 
Administration, Volume /. Concepts and Principles; Volume 2: 
Medical Care Appraisal and the periodicals, American 
Journal of Public Health and The Nation's Health. A 
publications list is available on request. 

Group Health Association of America (GHAA) 

1 129 20th Street, NW, Suite 600 
Washington, DC 20036 
Phone: 202-778-3268 
Fax: 202-331-7487 

GHAA is the leading national association for health 
maintenance organizations (HMOs) with over 360 members. 
The Government Affairs staff provides leadership in the 
development of health care policy and legislative advocacy 
for members. The Association conducts research, providing 
vital statistics and analyses of prepaid health care trends. 
Through its educational affiliate, the Group Health Foundation, 
a wide range of conferences, seminars and workshops are 
offered each year. The National HMO Policy Conference is 
held annually in January in Washington, DC. The GHAA's 
library houses the most extensive collection of works on 
prepaid, managed care and is an important source of 
information on all existing HMO laws and regulations, as well 
as pending bills. Publications include, National Directory of 



Appendix 2 



HMOs; HMO Industry Profile; Patterns in HMO Enrollment, 
and the serials, HMO Magazine and HMO Managers Latter. 
A publications list is available on request. 

Health Insurance Association of America (HIAA) 

1025 Connecticut Avenue, N.W. 
Washington, DC 20036-3998 
Phone: 202-223-7780 
Fax: 202-828-451 1 

The HIAA is a membership organization representing the 
commercial health insurance industry In the United States. The 
Association advocates for its 270 members in both the 
Federal and state governments, The HIAA provides forums, 
meetings and educational programs, HIAA's Coalition for 
Health Insurance Choices represents numerous groups across 
the country. The Policy Development and Research division 
publishes The Source Book of Health Insurance Data which 
sets the standard for data on the insurance industry. Other 
publications include, Insurer-Sponsored Managed Health 
Care, The Fundamentals of Managed Care, and Health Care 
Financing for All Americans. Periodicals include, Managed 
Core Bulletin; Campaign Update, and Legislative Bulletin, A 
publications list is available on request. 



Medical Group Management Association (MGMA) 

1 04 Invornoss Terraco East 
Englewood, CO 801 12-5306 
Phono: 303-799-1 1 1 1 
Fox: 303-643-4427 
Publications: 303-397-7888 

The Association is llio oldest and largest membership 
organization of its kind dedicated to the business of medicine. 
MGMA has two allied organizations, the American College of 
Medical Practice Executives and the Center for Research in 
Ambulatory Health Care Administration. MGMA maintains a 
biographical archive and library of 5,000 volumes and 200 
journals on group practice administration. Periodical titles 
include, Medical Croup Management Journal and Medical 
Croup Managemonl Update. Publications include, Integrated 
Health Care: Reorganizing the Physician, Hospital and 
Health Plan Relationship; Integrated Health Care: Case 
Studies; Case Management in Primary Care: A Manual; 
Introduction to Managed Care; The Managed Care 
Assembly Directory; Building Referral Networks Search 
Summary Packet, and Utilization ol Medical Services. A 
catalog is available on request. 

National Association of Community Health Centers 
(NACHC) 

1330 New Hampshire Avenue, N.W., Suite 122 
Washington, DC 20036 
Phone: 202-659-8008 
Fax: 202-659-8519 

The Association is the leading membership organization 
which advocates on behalf of community-oriented primary 
health care programs and the millions of medically 



underserved and uninsured people they serve. NACHC 
provides legislative advocacy, education and training, 
information and technical assistance. An annual conference is 
held each September. Publications include. Health Care, 
Access and Equality: The Story of Community and Migrant 
Health Centers and Their National Association; Community 
and Migrant Health Centers: A Key Component of the U.S. 
Health Care System, Access to Community Health Care: A 
State and National Databook, and Improving Access to Care 
for Hard-to-Reoch Populations. A publications list is available 
on request. 

National Association of County Health Officials 
(NACHO) 

c/o National Association of Counties 
440 1 st Street NW, Suite 500 
Washington, DC 20001 
Phone: 202-783-5550 
Fax: 202-783-1583 

The purpose of the 2,000 member NACHO is to contribute to 
the improvement of county health programs and public health 
practices throughout the US; to provide information on county 
health programs and practices; and to participate in the 
formulation of the policies of the National Association of 
Counties. NACHO is developing a self-assessment instrument 
for use by local health officials and operates the Primary Care 
Project which helps to strengthen the link between local health 
departments and community health centers. Publications 
include the monthly FYI, and bimonthly NACHO News. 



Managed Care Market Area Self — Assessment Tool 



National Clearinghouse for 
Primary Care Information 

8201 Greensboro Drive, Suite 600 
McLean, VA 22102 
Phone: 703 821-8955 EXT: 248 
Fax: 703 821-2098 

The Clearinghouse provides information to support the 
planning, development and delivery of ambulatory health care 
to urban and rural areas where there are shortages of 
medical personnel and services. Its primary audience is health 
care providers who work in community and migrant health 
centers. The Clearinghouse produces a bibliography to assist 
health care professionals working in BPHC-supported projects 
locate and obtain relevant resources. Titled, The Development 
and Management of Ambulatory Care Programs, the 
bibliography includes reports, bibliographies, handbooks, 
manuals and directories on various topics including managed 
care and program development. Other relevant resources 
include, A Manual for Negotiations with Managed Care Plans 
and BPHC-Supported Primary Care Centers Directory. 

National Governors Association (NGA) 

Hall of the States 
444 North Capitol Street 
Washington, DC 20001 
Phone: 202-624-5300 
Fax: 202-624-5313 

The National Governors' Association was formed to provide a 
bipartisan forum, to help shape and implement national policy 
and to solve state problems. The NGA Center for Policy 
Research helps to improve policymaking and program 
management for priorities established by the Association. 



Appendix 2 



A yearly summer meeting deals with intorgovornmonlal issues, 
A yearly winter meeting focusos on slate-fodoral issues. 
Publications include, State Progress in Health Cam Reform; 
Caring for Kids: Strategies for Improving Stato Child Health 
Programs; Facilitating Health Caro Coverage for the Working 
Uninsured, and State Initiatives to Improve Rural Health Caro. 
A publications list is available on request. 

National Medical Association (NMA) 

1012 10th Street, NW 
Washington, DC 20001 
Phone: 202-347-1895 
Fax: 202-842-3293 

The Association was founded in 1895 as the National 
Association of Colored Physicians, Dentists and Pharmacists. 
While the National Medical Association has focused primarily 
on health issues related to African Americans, its principles, 
goals, initiatives and philosophy encompass all sectors of the 
population, The NMA is actively involved in the national 
health care reform debate, lobbying for a secure health care 
system that reflects the needs and interest of minorities and 
other unserved and underserved populations. NMA activities 
include, an annual scientific conference; continuing education 
programs; the National Minority Mentor Recruitment Network; 
AIDS education; domestic violence physician screening 
education; prisoner health education; supporting the 
supplemental food program (WIC) as well as Head Start and 
Job Corps. Publications include, Journal of the National 
Medical Association and National Medical Association News. 



55 



Notional Rural Health Association 
National Service Center 

One WgsI Armour Blvd., Suite 301 
Kansas City, MO. 64 1 1 1 
Phono: 816-756-3140 
Fox: 81 6756-3 144 

TIig Association is a national non-profit membership 
organization providing the primary leadership on rural health 
in America, There are seven constituency groups which help 
to develop Association policy: Clinical Services, Community- 
Operated Practices, Frontier, Hospitals, Population-Based 
Services, Research and Education and Statewide Health 
Resources, The Association holds an annual conference each 
spring. Publications include the quarterly, Journal of Rural 
Health; Rural Health Resources Directory; A Shared Vision: 
Building Bridges (or Rural Health Access — Conference 
Proceeding; Rural Primary Care Consortia: Organizational 
Development for the 1990s, and the monograph series, 
Alternative Models for Organizing and Delivering Health Care 
in Rural Areas which includes the title, independent Networks. 
A publications list is available on request. 



United States Conference of Local Health Officers 
(USCLHO) 

1 620 Eye Street, NW 
Washington, DC 20006 
Phone: 202-2937330 
Fax: 202-293-2352 

This organization of chief health officers, commissioners, 
directors and other officials representing city, county, or city- 
county health departments promotes cooperation and 
exchange of ideas to assist in the improvement of local public 
health administration. USCLHO also sponsors coordination of 
intergovernmental health agency efforts. Publications include 
the periodicals Local Health Department Directory, Local 
Health Officers News, and fact sheets on national policy and 
legislative developments. 



Managed Care Market Area Self — Assessment Tool 



REGION I 
ORGANIZATIONS 



Connecticut 

Laura Victoria Barrera 

Connecticut Department of Health 

Center for Health Policy Development 
1 50 Washington Street 
Hartford, CT 06106 

Judith Shea 

Connecticut Association of 
Primary Health Care Centers, Inc. 

30 Arbor Street North 
Hartford, CT 06106 

Maine 

Sophie Glidden 

Maine Department of Human Services 

35 Anthony Ave., Station 1 1 
Augusta, ME 04333-001 1 

Bonnie Post, Executive Director 
Maine Ambulatory Care Coalition 

PO Box 390 

Route 202, The Village Green 
Manchester, ME 04351 



Massachusetts 

Kim Sheets 

Massachusetts Department of Medical Security 

One Ashburton Place, Room 1 109 
Boston, MA 02 1 08 

James W. Hunt, Jr., Executive Director 

Massachusetts League of Community Health Centers 

100 Boylslon Street, Suite 31 1 
Boston, MA 02 1 1 6 

Delsie Hoyt, Lindsay Josephs 

Bi-State Health Center Association 

1 00 Boylston Street, Suite 7 1 
Boston, MA 02 1 1 6 

James Kanak, Executive Director 

New England Community Health Center Association 
(NECHCA) 

400 Cummings Park, Suite 4600 
Woburn, MA 01801 

New Hampshire 

John Bonds 

New Hampshire Department of Public Health 

Health and Welfare Building 

6 Hazen Drive 

Concord, NH 03301-6527 



Appendix 2 



Rhode Island 

Sharon Cagon 

Rhode Island Department of Health 

Division of Family Health 
3 Capitol Hill 
Providence, Rl 02908 

Barbara B. Colt, Director 

Rhode Island Health Center Association 

2845 Post Road, Room 1 10 
Warwick, Rl 02886 

Vermont 

Primary Care Specialist 

Vermont Department of Health 

P.O. Box 70 
Burlington, VT 05402 



REGION II 
ORGANIZATIONS 



New Jersey 

Victoria Wood 

New Jersey State Department of Health 

Family Health Services/Community Health Services 

50 East Stale Street, 6th Floor, CN-364 

Trenton, NJ 08625-0364 

Katherine Grant-Davis, Executive Director 

New Jersey Primary Care Association 

760 Alexander Road, CN-1 

Princeton, NJ 08543 

New York 

Gary Riviello 

New York State Department of Health 

Health Care Standards and Surveillance 
E.S.P, Corning Tower, Room 191 1 
Albany, NY 12237 

Ina Labiner, Executive Director 
Community Health Care Association 
of New York State, Inc. 

475 Riverside Drive, Suite 1252 
New York, NY 101 15 



58 



Managed Care Market Area Self — Assessment lool 



Puerto Rico 

Antonio, Silva-lglecia, M.D. 

Puerto Rico Department of Health 

Office of Federal Affairs 

P.O. Box 70139 

San Juan, PR 00936-8139 

Zenaida Fernandez, Executive Director 
Asociacion de Centros de Salud Comunal 
de Puerto Rico, Inc. 

Villa Nevarez Professional Center, Suite 406 
Rio Peidras, PR 00927 



REGION III 

Delaware 

Dr. Charles Konigsberg 

Delaware State Department of Health 

Delaware Health & Social Services 

Jesse Cooper Building 

Corner Federal & Water Streets 

PO Box 637 

Dover, DE 1 9903 



Appendix 2 



Washington, D.C. 

Dr. Carlessia Hussein 

District of Columbia Department of Health 

Office of Health Planning & Development 
1660 L Street, NW Suite 1117 
Washington, DC 20035 

Maryland 

Jonathan Foley 

Maryland Department of Health 
and Mental Hygiene 

Office of Planning and Analysis 
201 West Preston Street, 5th Floor 
Baltimore, MD 21201 

Terri Richardson 

Maryland, Delaware, District of Columbia 
Mid-Atlantic Association of 
Community Health Centers 

1460 Governor Ritchie Highway, Suite 204 
Arnold, MD 21012 

Pennsylvania 

Joseph May, Deputy Secretary for Community Heal 
Pennsylvania Department of Health 

Health & Welfare Building, Room 815 
P.O. Box 90— 7th & Forster Streets 
Harrisburg, PA 17120 



Honry Fiumolli 

Pennsylvania Forum for Primary Health Care 

600 North Second Sltoel 
Wormloysburg, PA 17043-1002 

Virginia 

E. George Stone, Director 
Virginia Department of Health 

Virginia Cooperative Agreement for Primary Health Care 
1500 E. Main Street, Suite 213 
Richmond, VA 23219 

John B. Cafazza, Jr., Executive Director 
Virginia Primary Care Association, Inc. 

10800 Midlothian Turnpike, Suits 265 
Richmond, VA 23235 

West Virginia 

Charles W. Dawkins 

West Virginia Department of 

Health and Human Resources 

1411 Virginia Street, East 
Charleston, WV 25301 

Jill Hutchinson, Executive Director 
West Virginia Association of 
Community Health Centers, Inc. 

1219 Virginia Street East 
Charleston, WV 25301 



Managed Care Market 



REGION IV 
ORGANIZATIONS 



Alabama 

Sherrie A. Cooke 

Alabama Cooperative Agreement Grantee 

3 1 2 Montgomery Street, 7th Floor 
Montgomery, AL 36104 

Ray Overton, Executive Director 

Alabama Primary Health Care Association 

6013 East Shirley Lane, Suite A 
Montgomery, AL 361 17 

Florida 

Gregory J. Glass 

Florida Department of Health and 
Rehabilitative Services 

Stale Health Office (HSAH) 
1323 Winewood Boulevard 
Tallahassee, FL 32399-0700 

Susan A. Moore, Executive Director 
Florida Association of CHCs, Inc. 

5840-B South Semoran Boulevard 
Orlando, FL 32822 



Area Self — Assessment Tool 



Georgia 

Rita Salain 

Georgia Department of Human Resources 

Division of Public Health 
2 Peachtree Street, 6th Floor 
Atlanta, GA 30303 

Mickey L. Goodson, Executive Director 

Georgia Association for Primary Health Care 

Post Office 1 029 

2 Peachtree Street, 8lh Floor 

Atlanta, GA 30301 

Kentucky 

Danise Newton 

Kentucky State Department of Health 

275 E. Main Street 
Frankfort, KY 40601 

Joseph E. Smith, Executive Director 
Kentucky Primary Care Association 

226 West Main Street 
PO Box 751 
Frankfort, KY 40602 

Mississippi 

Perila Taylor 

Mississippi State Department of Health 

Bureau of Health Resources 

P.O. Box 1700 

Jackson, MS 39215-1700 



Robert M Pugh, Executive Director 

Mississippi Primary Health Care Association 

860 East River Place, Suite 1 03 
Jackson, MS 39202 

North Carolina 

Burnie Patterson 

North Carolina Department of Human Resources 

Office of Rural Health and Resource Development 
3 1 1 Ashe Avenue 
Raleigh, NC 27606 

Steven E. Shore, Executive Director 

North Carolina Primary Health Care Association 

975 Walnut Street, Suite 355 
Cory, NC 275 1 1 

South Carolina 

Tom McGee 

South Carolina Department of Health and 
Environmental Control 

Office of Rural Health, Migrant Health and Primary Care 
2600 Bull Street 
Columbia, SC 29201 

Lathran Woodard, Executive Director 

South Carolina Primary Care Association 

1321 Lady Street 
PO Box 6923 

Columbia, SC 29260-6923 



Appendix 2 



Tennessee 

Eloise Halmaker, NGA Contact 

Tennessee Department of Health and Environment 
Bureau of Health Services 

536 Cordoll Hull Building 
Nashville, TN 37247-5410 

Doniso Kirsch 

Community Health Agency Support 

Tonnosseo Department of Health 
536 Cordell Hull Building 
Nashville, TN 37247 

Kathy Wood-Dobbins, Executive Director 
Tennessee Primary Care Association 

Parkvlow Towers, Suite N-102 
205 Reidliurst Avenue 
Nashvillo, TN 37203 



REGION V 
ORGANIZATIONS 



Illinois 

Roger Ricketts 

Illinois Department of Health 

535 West Jefferson Street 
Springfield, IL 62761 

Ion M. Berkeley, Executive Director 

Illinois Primary Health Care Association 

600 S. Federal, Suite 700 
Chicago, IL 60605 

Indiana 

Keith Main 

Indiana State Board of Health 

1330 W. Michigan Street 
P.O. Box 1964 
Indianapolis, IN 46206-1964 

Kathleen Disinger 

Indiana Cooperative Agreement 

Indiana State Department of Health 
1330 W. Michigan Street 
P.O. Box 1964, Room 332W 
Indianapolis, IN 46206-1964 



62 Managed Care Market Area Self — Assessment Tool 



Kayla West, Executive Director 

Indiana Primary Health Care Association, Inc 

1650 N. College 
Indianapolis, IN 46202 

Michigan 

Beth Ann Pridnia, Director of Project 
Michigan Department of Public Health 

Bureau of Health Systems 
Division of Managed Care 
3423 N. Logan/MLK Boulevard 
Lansing, Michigan 48909 

Sarah E. Banks-Lang, Executive Director 
Michigan Primary Care Association 

1305 Abbott Road, Suite 101 
East Lansing, Ml 48823 

Minnesota 

Phebe Conrey, CA Grantee Contact 
Office of Rural Health 

Minnesota Department of Health 
717 Delaware Street, S.E. 
Minneapolis, MN 55440-9441 

Alan Strange, Executive Director 

Minnesota Primary Care Association, Inc. 

1315 24lh Street 
Minneapolis, MN 55404 



Ohio 

Susan Ewing Ramsay 

Ohio Department of Health 

Office of Health Resources 
246 N. High Street 
P.O. Box 118 

Columbus, OH 43266-01 18 
Marcia Miller 

Ohio Primary Care Association 

341 S. Third Street, Suite 301 
Columbus, Ohio 43215 

Wisconsin 

Ken Baldwin 

Wisconsin Department of Health 
and Social Services 

Division of Health 
Bureau of Public Health 
1414 East Washington Avenue 
Madison, Wl 53703 

Susan Robillard 

Wisconsin Primary Health Care Association 

5721 Odana Road 
Madison, Wl 53719 



Appendix 2 



REGION VI 
ORGANIZATIONS 



Arkansas 

Tommy L Sproles, Director 
Arkansas Department of Health 

Office of Primary Care 
4815 W. Markham Street 
little Rock, AR 72205-3867 

Norton Wilson, Executive Director 

Community Health Centers of Arkansas, Inc. 

4815 W. Broadway, Suite K 
North Utile Rock, AR 721 14 

Louisiana 

Marcia Daigle 

Louisiana Department of Health and Hospitals 

Division of Policy and Program Development 
Box 1349 

Baton Rouge, LA 70821-1349 

Shirley Marcus, Executive Director 

Louisiana Primary Care Association, Inc. 

439 N. 1 1 Ih Street 

Baton Rouge, LA 70802-4608 



Managed Care Market 



New Mexico 

Harvey Licht 

New Mexico Department of Health 

Public Health Division 
P.O. Box 261 10 
Sanle Fe, NM 87503 

David Roody, Executive Director 

New Mexico Primary Care Association 

2309 Renard, SE, Suite 209 
Albuquerque, NM 87106 

Oklahoma 

Mary Helen Smith 

Oklahoma State Department of Health 

1000 NE 10th Street 
Oklahoma City, OK 731 17-1299 

Texas 

Barry Good 

Texas Department of Health 

Primary Health Care Services 
1 1 00 W. 49th Street 
Austin, TX 78756 

Jose Camacho, J.D. 
Executive Director 
Texas Association of 
Community Health Centers, Inc. 

21 1 East 7th Street, Suite 818 
Austin, TX 78701 



Area Self — Assessment Tool 



REGION VII 
ORGANIZATIONS 



Ben Pettus 

Missouri Coalition for Primary Health Care and 
Heartland Primary Care Association 

5 1 4 E. Capital, Suite A 
Jefferson City, MO 65109 



Iowa 

Sharon L. Cook 

Iowa Department of Public Health 

Office of Health Planning 
Lucas State Office Building 
E. 12th and Grand, 4th Floor 
Des Moines, IA 503 1 9 



Nebraska 

David Palm 

Nebraska Department of Health 

Office of Rural Health 
P.O. Box 95007 
Lincoln, NE 68509 



Thomas Slater, Executive Director 
Iowa-Nebraska Primary Care Association 

1 00 Court Avenue, Suite 3 1 2 
Des Moines, IA 50309 

Kansas 

Joyce Volmut 

Kansas Department of Health and Environment 

900 Southwest Jackson 
Topeka, KS 66612 

Missouri 

George Thomas 

Missouri Department of Health 

Division of Local Health and Institutional Services 

P.O. Box 570 

Jefferson City, MO 65 1 02 



Appendix 2 



REGION VIII 
ORGANIZATIONS 



Colorado 

Lindy Nolson, Director 

Rural and Primary Health Policy and Planning 

Colorado Department of Health 

FCHSD-RPH-A4 

4300 Cherry Creek Drive South 
Denver, CO 80222-1530 

Maureen Hong, Executive Director 
Community Health Association of the 
Mountain/Plains States (CHAMPS) 

800 Grant, Suite 505 
Denver, CO 80203 

Maureen Hong, Executive Director 
Colorado Community Health Network 

800 Grant, Suite 505 
Denver, CO 80203 

Montana 

J. Dale Taliaferro, NGA Contact 

Montana Department of Health and Environmental 

Caswell Building 
Helena, MT 56920 



Managed Care Market 



Frank S. Newman 
Montana AHEC 

308 Culbertson Hall 
Montana State University 
Bozeman, MT 59717 

Allen Strange 

Montana Primary Care Association 

P.O. Box 1720 

Helena, Montana 59624 

North Dakota 

Mary Amundson 
University of North Dakota 
Center for Rural Health 
501 N. Columbia Road 
Grand Forks, ND 58203 

Cindy Smith 

Trudy Stauffacher, R.N., B.S.N., M.M. 
Public Health Consultant 
North Dakota Department of Health 
and Consolidated Laboratories 

600 E. Boulevard Avenue 
Bismarck, ND 58505-0200 



Area Self — Assessment Tool 



South Dakota 

Bernard Osberg 

Deb Hailing, Grantee Contact 

South Dakota Department of Health 

Office of Rural Health 
445 East Capital Avenue 
Pierre, South Dakota 57501 

Deb Hailing 

Debra Muller, Health Program Specialist 
South Dakota Health Department 

Office of Rural Health 
445 East Capitol Avenue 
Pierre, SD 57501-3185 

Scott Graff, Executive Director 

Dakota Association of 

Community Health Centers (DACHC) 

c/o Office of Rural Health 

800 East 2 1 si Street 

Sioux Falls, SD 571 17-5045 

Utah 

Robert W. Sherwood 

Utah Department of Health 

Bureau of Local and Rural Health Services 

P.O. Box 16990 

Salt Lake City, UT 841 16-0990 



Appendix 1 



Bette Vierra, Executive Director 
Association for Utah 
Community Health Centers, Inc. 

2300 West 1 700 South 
Salt Lake City, UT 84104 

Wyoming 

Douglas Thiede, Management Consultant 
Wyoming Department of Health 

134 Hathaway Building, Room 1 17 
Cheyenne, WY 82002-0840 

Beverly Morrow, Resource Developer 
Wyoming Department of Health 

1 17 Hathaway Building 
Cheyenne, WY 82002 



REGION IX 
ORGANIZATIONS 



Arizona 

Tracy Kirkman-Lilf, Grantee Conlacl 
Arizona Department of Health Services 

Office of Planning and Heallh Statistics Monitoring 
1740 West Adams, Room 312 
Phoonix, AZ 85007 

Andrew Rinde, Executive Director 
Arizona Association of Community Health Cent< 
Inc. 

320 E. McDowell Street, Suite 225 
Phoonix, AZ 85004 

California 

Mark Holmor, Director of Project 

California Department of Health Services 

Rural and Community Health Division 
Primary Heallh Care Systems Branch 
714 P Street, Room 599 
Sacramento, California 95814 



Managed Care Market 



Hawaii 

Charlene Gasper 

Hawaii State Department of Health 

Personal Health Service Administration 
3652 Kilauea Avenue 
Honolulu, HI 96816 

Ginny Baresch 

Hawaii Primary Care Association 

Crystal Building 

3442 Waialae Avenue, Suite 1 

Honolulu, HI 96816 

>«' Nevada 

Maria D. Canfield, Manager 

Nevada Department of Human Resources 

Health Division, Primary Care Development Center 
505 E. King Street, Room 203 
Carson City, NV 89710 



Area Self — Assessment feel 



REGION X 
ORGANIZATIONS 



Alaska 

Deborah Erickson, Director of Project 

Alaska Department of Health and Social Services 

Division of Public Health 
Mail Stop 0610 
P.O. Box H 

Juneau, AK 9981 1-0610 
Idaho 

Diane Bowen 

Idaho Department of Health and Welfare 

Office of Health Policy and Resource Development 
450 W. Slate Street, Fourth Floor 
Boise, ID 83720 

Dean Hungerford, Executive Director 
Idaho Primary Care Association 

4948 Kootenai, Suite 203 
Boise, ID 83707 

Oregon 

Rebecca Landau 

Oregon Health Division 

800 NE Oregon Street #21, Suite 948 
Portland, OR 97232 



Appendix 2 



Ian Timm, Executive Director 

Oregon Primary Care Association 

1220 Southwest Morrison Avonuo, Suite 435 
Portland, OR 97205 

Washington 

Mary Looker 

Washington Department of Health 

Office Of Community and Rural Health 

PO Box 47834 

Olympic, WA 98504-7834 

Tom Trompeter, Executive Director 
Northwest Regional Primary Care 
Association (NWRPCA) 

4154 California Avenue, SW 
Seattle, Washington 981 16 

Lilia Lopez, Acting Executive Director 
Washington Association of 
Community Health Centers 

1 10 East 5th Street 
Olympic, WA 98501 



APPENDIX 3 



Managed Care Organization 
Performance Indicators 



70 



Managed Care Market flrea Self — Assessment I 



PERFORMANCE INDICATORS 



Total Membership 

Description Tolal number of members enrolled at the end 
of the report period. 

Total Revenue 
Description Income generated from operations. 
Definition Same as Description. 

NAIC Total Revenue — Report 2, Line 7, Column 2. 
Range Not applicable. 



Net Income 
Description 
Definition 
NAIC 
Range 



Amount of excess revenue after expenses. 
Total Revenue — Total Expenses. 
Net Income — Report 2, Line 32, Column 2. 
Greater than 50. 



Net Worth 

DescriptionAmounl of excess assets after liabilities. 
DefinitionTotal Assets — Total Liabilities. 
NAICNet Worth— Report 2, Line 42, Column 1 . 
RangeNet Worth Per Member is greater than $50. 

Operating Profit Margin 



Description 



Definition 
NAIC 
Range 



Indicates the overall profitability of the health 
plan. The operating profit margin indicates the 
percentage of revenue that goes to net 
income. 

100%— Overall Loss Ratio. 
See Overall Loss Ratio. 
Not Applicable. 



Appendix 3 



LIQUIDITY INDICATORS 



Days Cash On Hand 
Description The amount of days llio hoalth plan could go 
lo cover operating oxponsos with tho curront 
amount of availablo cash. 
Definition (Cash + Short Term lnvoslmonls)/(Tolal 

Medical and Hospital Exponsosl/365. NAIC: 
Cash — Report I, Part A, Lino 1, Column 1. 

Short Term Investments — Report I, Part A, 
Line 2, Column I. Tolal Medical and Hospital 
Expenses — Report 2, Lino 21, Column 2. 
Range Indicated rango is greater than 25 days. 

Ratio of Cash to Claims Payable 
Description Indicates tho effectiveness of a plan's ability 
to pay off accounts payable with availablo 
cash, 

Definition Cash / Claims Payable. 

NAIC Cash—Report 1, Part A, Lino I, Column 1. 
Claims Payable— Report 1, Part B, Line 2, 
Column 3. 

Range Indicated range is greater than 1 ,0. 
Note This indicator is applicable to IPA and 
certain group model plans only. 



EFFICIENCY INDICATORS 



Definition 



NAIC 



Days in Receivables 

Description Indicates tho number of days of revenue lhat 
members owe a heallh plan. 
Premiums Receivable / [(Total Premium 
Revenue + Foe for Service Revenue + 
Medicare Revenuo + Medicaid Revenue) / 
365]. 

Premiums Receivable— Report 1, Pari A, Line 
3, Column 1. Total Premium Revenue — Report 
2, Line I, Column 2. Fee for Service 
Revenue— Report 2, Line 2, Column 2. 
Medicare Revenue — Report 2, Line 3, 
Column 2. Medicaid Revenue— Report 2, 
Line 4, Column 2. 

Range Indicated range should be greater than 0. 
Days in Unpaid Claims 



Description 
Definition 
NAIC 

Range 



Indicates the number of days of claims a 
health plan owes its members, 

Claims Payable / [Total Health Care 
Expenses / 365]. 

Claims Payable— Report 1, Part B, Line 2, 
Column 3. Total Health Care Expenses- 
Report 2, Line 21, Column 2. 
Indicated range should be greater than 0. 



Managed Care Market 



STATUTORY INDICATORS 

Admitted Reserves 

(Sometimes referred to as tangible net worth) 
Description Funds available lo buffer the plan from 
financial shortfalls. 
Definition Admitted Assets— All Liabilities. 

NAIC Admitted Assets— Schedule Fl, Line 19, 

Column 3. All Liabilities— Report 1, Part B, 
Line 1 3, Column 3. 
Range At a minimum, the plan must meet State 
Minimum Reserve Requirements. 

State Minimum Reserve Requirements 
Description The minimum state reserve requirement. 
Definition Defined by each state. 
NAIC Not Applicable. 
Range Not Applicable. 
Note Please provide the state minimum 

requirements for all states that require you to 
maintain a reserve, the amount of the 
reserve, and the amount of reserve you are 
holding in those slates 



ea Self — Assessment fool 



PROPERTY OF 
JAN 3 1 jg 97 

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